Patient Education and Counseling 70 (2008) 227233

www.elsevier.com/locate/pateducou

Nurse training of a patient-centered information

procedure for CABG patients
Svein Bergvik *, Rolf Wynn, Tore Srlie
Department of Clinical Psychiatry, Institute of Clinical Medicine, University of Troms, Norway
Received 8 August 2007; received in revised form 5 October 2007; accepted 22 October 2007

Abstract
Objective: At the study hospital, all elective coronary artery bypass graft (CABG) surgery patients were given similar, standardized information by
the nurses. The nurses reported problems in establishing contact and interacting with patients when using this approach. To help remedy
communication problems between nurses and CABG patients, a programme training nurses in a patient-centred information procedure was
developed and implemented. This article describes how challenging interactions were recorded and analysed for training nurses in the patientcentred approach.
Method: In group training for patient-centeredness, nurses presented audio-recordings of nursepatient interactions they found problematic. These
were used as a basis for discussions and training in the patient-centered approach. A set of cases was developed using a qualitative
phenomenological approach, illustrating how the patient-centered approach could be applied to the difficult situations.
Results: The nurses found the patient-centered approach particularly useful in situations when patients frequently asked questions, seemed to have
difficulties expressing their worries, frequently complained, or when spouses expressed worries.
Conclusion: Nurses found the patient-centered approach and the training procedure used in this study useful in their clinical work with CABG
patients.
Practice implications: This training which requires minimal resources and can be easily implemented, may guide the nurses in their interaction
with patients. Providing a patient-centered approach to the CABG patients may enhance the nursepatient contact and improve patients hospital
experience and subjective health.
# 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient centered; Patient information; Nurse training; Nursepatient interaction; Coronary artery bypass graft surgery; Self-regulation; Qualitative
method

1. Introduction
Coronary artery bypass graft (CABG) surgery is physically
and psychologically stressful. Patients perceive the surgery as a
life-threatening event, have problems adapting to the hospital
routines, feel a lack of control, and find that hospitalization
separates them from family, friends and their everyday life
context [16]. Subjective stress is found to be highest prior to
admission and at discharge from hospital, and relatively lower 2
and 4 months following discharge [7]. However, negative
subjective and functional consequences of surgery are reported

* Corresponding author at: PO Box 6124 Asgard, University Hospital of

Northern Norway, 9291 Troms, Norway. Tel.: +47 97184448;
fax: +47 77627806.
E-mail address: svein.bergvik@unn.no (S. Bergvik).
0738-3991/$ see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.10.013

several years following discharge [8]. The high prevalence of

stress, anxiety and depression in coronary patients [914] may
have serious implications, as both pre- and post-operative
anxiety and depression predict poorer postoperative outcome
[1517,12].
Provision of information is an integral part of most
psychological interventions proved effective, and procedures
include procedural information, sensation information, behavioral instructions, cognitive behavioral approaches, emotion
focused/psychotherapeutic interventions, and various combinations of these [8]. Information provided by videotape has
improved patients decision making [18], self-efficacy beliefs,
recovery [19], diet and exercise after CABG [20]. Interventions
combining various preparation methods appear to be most
effective [8], and significant benefits have been reported on
negative affect, pain, the need for pain medication, the length of
hospital stay, behavioral indices of recovery, physiological

228

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

indices, and satisfaction [8,2125]. Interventions appear to be

most effective when they are tailored to each individuals
coping style [21,26]. Individualized patient education has
successfully been applied to cardiac patients both individually
[27] and in group contexts [28], and general psychotherapeutic
principles have been found effective in reducing emotional
distress in surgical patients [8,21].
Clinicians and researchers have argued for a biopsychosocial perspective and a patient-centered approach to meet the
patients need for information and support [2936]. A patientcentered approach is characterized by emphasizing the
importance of the personal meaning of the illness for the
individual patient, sensitivity to the patients preferences for
information and shared decision-making, developing common
therapeutic goals and enhancing the personal bond between
provider and patient, and awareness of the influence of the
personal qualities and subjectivity of the provider on the
practice of medicine [31]. The importance of patientcenteredness has been demonstrated both in primary care
[32,33] and in various hospital settings [34,3739], and
interventions emphasizing the active contribution of the patient
are more consistently associated with positive health outcomes
than simple informational interventions [31].
In theories of self-regulation [40], humans are perceived as
goal-oriented systems, regulating their actions in ways aimed
at attaining certain goals, such as avoiding risks or obtaining
good health [41,42]. Self-regulation may include both
intrapersonal processes such as cognitive appraisal and
coping, and interpersonal processes involving healthcare
providers, family, and friends. Thus, within a self-regulation
framework, a patient-centered intervention should stimulate
the active self-regulatory mechanisms of the individual
patient, including cognitive, emotional, behavioral and social
processes.
Nurse information to CABG surgery patients at the
University hospital of Northern Norway has been standardized,
all patients receiving the same information according to a
checklist. While the various specialists provide specific
information related to their treatment, ward nurses are
responsible for giving the general information and supporting
the patients [43,44]. Preoperatively, this includes procedural
and sensory information related to the diagnostic procedures
and treatment, along with some behavioral instructions.
Postoperatively, the information focuses on preventive life
style changes and mastering the situation at home. The
approach has been nurse-centered, with the nurse in the role of a
decision-maker, controlling the informational process and
providing a high amount of detailed information in a relatively
short period of time. The patient has been a passive receiver of
information, with minimal control and participation in the
information process. The sessions have taken place at various
locations at the ward, and have often been disturbed or
interrupted by phone calls, other staff or patients who needed
assistance.
In informal conversations with the authors, the ward nurses
have expressed their frustration, not being able to establish the
necessary contact and rapport with the patients during the busy

days at the ward. The significance of the relationship between

the quality of the nursepatient contact and patients
satisfaction with information has been documented in a
previous study [45].
We therefore joined forces with a group of ward nurses, in an
attempt to develop a programme for training nurses to inform
and support CABG patients in a patient-centered way, as
described below. The effect of the nurse-training programme on
patient outcome has been documented in a randomized
controlled trial reported in a previous article [44].
2. Methods
2.1. The hospital
The study took place at the Department of Thoracic and
Vascular Surgery at the University Hospital of Northern
Norway. This is a 23-bed ward treating approximately 1500
patients per year (2006), including 600 CABG surgery
patients.
2.2. The participating nurses and the supervisor
Four female nurses, age 2237, participated in the study.
They were employed full-time at the ward, and all had more
than 5 years experience in nursing CABG patients. The
supervisor (third author) was a male psychiatrist, age 60,
trained in individual and group psychotherapy.
2.3. The patients and the information sessions
The sample consisted of 55 patients treated at the
Department of Thoracic and Vascular Surgery. This included
46 males and 9 females, with a mean age of 58.2 years
(S.D. = 6.4) and a mean of 8.8 years of education (S.D. = 3.1).
One patient was Saami, the remaining were ethnic Norwegians.
All patients had a 40-minutes information session with a nurse
upon admittance and at discharge. Spouses and friends were
encouraged to participate, and they attended in about half of the
admission sessions and about every fifth of the discharge
sessions. As a mean to unveil the patients thoughts and worries
and stimulate curiosity and discussion, an information video
illustrating the hospital stay from a patient perspective was
shown during the admission session. The video had also been
enclosed with the letter of appointment sent home to the
patients prior to the admission.
2.4. The nurse training
The nurse training was organized as group meetings of 45minutes every other week over a 2-year period. The main tasks
of the group were (1) to identify and describe situations the
nurses found difficult when interacting with patients, (2) to train
the nurses in the patient-centered approach, and (3) to stimulate
nurses to reflect on how to apply the patient-centered approach
in various situations, and (4) to develop illustrative cases based
on the material presented in the group.

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

Box 1. Identifying challenging situations and generating illustrative case descriptions

1. Listen through the recordings
2. Identify difficult situations and efforts to apply the
patient-centered method
3. Make clear and simple formulations of the situations
and the patient-centered efforts
4. Explore the meaning this may represent to the
patients and the nurses and how the patient-centered
method may effect it
5. Discuss data and develop illustrative cases

2.4.1. Identifying difficult situations of nursepatient

interaction
During the training period, the nurses tape-recorded their
admittance- and discharge-consultations with patients. A
phenomenological approach for data analysis was used (see
Box 1), inspired by the method of meaning condensation by
Giorgi [46]. Prior to the group meetings, nurses listened
through their recordings and selected examples of difficult
situations. The selected tape recordings were presented to the
group and explored and discussed, both from the perspective of
the information providing nurses and the patients. The process
was carefully moderated by the supervisor, ensuring that the
discussion was held in a positive and constructive way,
supporting and empowering the competence and resources of
the individual nurses.
2.4.2. Training in patient-centeredness
The training procedure was based on recommendations for
a patient-centered information providing approach
[32,33,47], supplemented by general principles of psychotherapeutic rapport and alliance [48], and clinical
interview and listening techniques [49]. The following aims
were formulated: (a) develop a trusting relationship with a
listening, supportive and confirming attitude within an
undisturbed setting, (b) encourage the patients to express
any worries, feelings or aspects of their situation they deemed
important, (c) meet a preoccupation with painful emotions
and situational problems (fear of complications and death,
loss of contact with family and friends, feelings of hopelessness and depression, worries about future physical and
working ability, etc.) with a supportive and information
providing style, (d) provide support and information that is
congruent with the focus of the patient, (e) add important
information not covered by the questions asked by the patient
according to the checklist of the control group information,
and (f) motivate patients to seek information and to share
their thoughts and feelings with their families and friends,
thus stimulate them to utilize the social component of their
self-regulating activity [50,51].
A list of 11 recommended behaviors or actions was provided
(See Box 2).
The aims and recommendations were used to guide the
nurses when interacting with patients, and when listening to and
discussing the tape-recordings. The supervisor taught the

229

Box 2. List of 11 recommended behaviors

1. Adapt to patients language and personal style in a
way that promotes contact and trust
2. Use intuition as a guide for the approach to the
patient
3. Listen to what the patient is saying
4. Propose for the patient what he/she might be
wondering about
5. Help the patient to clarify unclear statements
6. Show interest in the feelings of the patient
7. Follow the focus of the patient
8. Provide information related to the questions of the
patient
9. Provide information about important topics not
covered by the questions of the patient
10. Correct misunderstandings of the patient
11. Test patients understanding of the provided information

fundamentals of patient-centeredness and how it can be

applied, using the nurses own experiences as examples.
2.4.3. Developing illustrative cases
The materials presented by the nurses included situations
where they applied the patient-centered method. The group
compared and discussed the situations, guided by the aims and
the list of recommended behavior. A set of case descriptions
was developed, illustrating the patient-centered method
applied in the difficult situations. The supervisor gradually
refined the illustrative cases as the discussions in the group
developed.
These case descriptions are aggregates of nursepatient
situations experienced by the four nurses with a number of
patients, a method resembling the collective case description
procedure described by Stakes [52].
2.5. Ethics
Informed consent was obtained from all participating
patients and the study was approved by the Regional
Committee for Medical Research Ethics and the Norwegian
Social Sciences Data Services.
3. Results
3.1. The training group
A total of 110 patient information sessions (admittance and
discharge sessions with 55 patients) were audio taped, and
selections from 37 of these were presented to the group. The
nurses and the supervisor found audio taping to be a useful
training tool, and the tapes were used systematically by the
supervisor for feedback and discussion in the group. The nurses
found that the training increased their awareness of their own as
well as their patients emotional reactions and how emotions
affected the interaction with the patients.

230

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

3.2. Interacting with patients

Adapting to the individual patient is central in the patientcentered approach. Thus, due to differences in their personal
style and life situations, patients were to be approached
differently. This differed from the prior standardized procedure
by which all patients got the same approach and information.
The nurses found the patient information video useful when
interacting with patients. The video could be helpful in
introducing relevant topics, in reminding the patients of their
questions and worries, and in promoting the dialogue. The
video also supported the nurses when interacting with patients
who were quiet and asked few questions. The video stimulated
the patients associations and the open-ended questioning style
of the patient-centered method invited and provided room for
the patients to formulate their own thoughts and feelings.
It was also the impression of the training group that the
patient-centered method may have lowered the patients
threshold for making contact and invited to a more open
nursepatient interaction in general at the ward.
3.3. Illustrative cases of nursepatient interaction
The nurse training resulted in a set of case descriptions
illustrating difficult nursepatient interaction, and how the
patient-centered approach could be applied in these situations.
As the nurses frequently described situations they found easy to
deal with, the first description represents the least problematic
situations, while the other paragraphs (3.3.23.3.5) represent
the more challenging situations.
3.3.1. When patients openly expressed their worries and
concerns
The nurses found the majority of their interactions with
patients unproblematic. This was particularly true when
interacting with patients who openly expressed their worries
and concerns. In these situations, the nurses succeeded in
providing a dialogue from the very beginning, and the patients
were actively co-operating with the information providing
nurses about their care. The patients questions often referred to
situations in their own life that had been illustrated by the video.
The nurses found the patients emotional reactions adequate for
the situation and they described having well functioning
interpersonal and supportive relationships to spouses and
friends with whom they often shared their worries and
questions.
3.3.2. When patients frequently repeated the same
questions
Some patients expressed a need for information about
various aspects of the illness, its treatment and prevention.
However, when information was provided, they were not
satisfied and frequently repeated the same questions over again.
When this became a pattern, the nurses often felt irritated and
wished to withdraw. The following vignette may illustrate this:
A female patient had repeatedly been asking for the prospects
of staying at a recreation home following the hospital stay.

Several times she had been properly informed about existing

options, but the information did not seem to satisfy her.
However, when she eventually was asked why this was so
important for her, she revealed a very complicated home
situation including a husband with alcohol problems and two
adult sons who were still living at home and expecting to be
cared for by their mother. This situation was associated with a
lot of shame, but after having talked to the nurse about it, it
became possible for her to plan her rehabilitation process
without being too much disturbed by her shame and bad
conscience for the situation at home. She was helped to express
her situation and needs directly to the family who in turn
appeared to be more helpful than she had expected. Thus, one
may hypothesize that the social component of her selfregulating activity became strongly improved.
A major challenge in meeting these patients was to
understand the meaning behind their questions. When the
nurses responded only to the manifest content of the questions,
no proper rapport was established. By helping these patients to
explore what made them ask so frequently for this information,
corresponding anxieties and worries were often disclosed. One
can theorize that their frequent questioning was a type of
defense against these corresponding worries. After having
expressed their worries, the nurses found that the patients
questions often appeared better anchored to their own
experiences, and that the information could more easily be
used by the patients in their self-regulating activity.
3.3.3. When patients seemed to have difficulties expressing
their worries
Some patients were perceived as suffering by the nurses, but
behaved as if they were not in need for any support or
information. The nurses often felt redundant, rejected and
helpless when interacting with them. A central task for the
nurses was to identify and reflect upon their own feelings when
interacting with the patients and avoid rejecting the patients in
the same way as they felt rejected by them. They were
instructed to inform the patients about central aspects of the
examinations, treatment, rehabilitation and prevention, and
encourage the patients to present any thoughts or worries as the
information was provided. Gradually, some of these patients
disclosed serious worries. One example was a relatively young
man who initially avoided any dialogue. The nurse perceived
him as silently suffering. After several unsuccessful attempts to
reach him, it appeared that he was convinced that he would be
completely invalidated by his illness. For him this meant
permanent loss of work, position, identity and meaning of life.
When he realized that his prognosis was much better than he
expected, this made him reevaluate the meaning of the coronary
disease and differentiate between problems related to his illness
and those that were not. It appeared that he over time had had
problems in reaching his ambitious professional goals at work.
This had made him feel worthless and convinced that there was
something wrong with him. The symptoms and the coronary
disease were perceived as a confirmation of his ideas of
personal failure. This kind of displacement or attribution of
various kinds of psychosocial problems to the illness was

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

frequently seen in these patients and obstructed a successful

self-regulation and improvement. The nurses experienced that
when they combined an active information providing activity
with an empathic attitude, the patients were enabled to
verbalize their worries and current life problems and to
construct a reality-based framework to guide self-regulation.
3.3.4. When patients frequently complained
Some patients frequently complained over various aspects of
their care, such as too little contact with the doctors, that the
waiting time prior to hospital admission had been too long, that
they had become too ill for surgery, that surgery had been
postponed, bad food, etc.
Once again, a major challenge was to establish contact and
rapport with the patients and to explore the meaning of their
feelings and complaints. This was often achieved by addressing
and exploring the meaning of their complaints directly. One
relatively young man was repeatedly complaining about the
absent doctors and asking for a consultation. However, despite
meeting the doctors, his behavior did not change. When the
nurse focused on this and helped him reflect on what made him
ask for the doctors all the time, the patient eventually told about
his loneliness and intense fear of dying. The patient came to
realize that the focus on the absent doctor had obscured the
emotional problematic issue, and could be understood as
serving as a representation of his own helplessness and fear of
dying. A central issue in the nurse training was how she could
avoid defending herself against the devaluating aspects of the
complaint, and be able to empathize with the patients
underlying feelings and fears. When the patient was helped
to express his fears and worries and allowed to reflect on how
these had colored his ideas of the disease and its treatment,
realistic information could be provided and used in the patients
self-regulating activity.
3.3.5. When spouses expressed worries
Spouses were encouraged to participate and did frequently
attend the information sessions. They often asked questions
both on behalf of themselves and their partners and provided
important support to the patient. However, some spouses
displayed more worries and need for control than could be
easily explained by the heart condition of the partner, and the
nurses found it difficult to respond to these spouses. The nurses
were trained to encourage the spouses to express their fears and
worries more fully. Often it became clear that their worries and
need for control were related to other problems than the illness,
such as their relationship to the patient, current socioeconomic
problems or their own health problems. When such background
factors were disclosed and discussed, the spouse usually
relaxed and was perceived by the nurse as a better co-operating
partner in the recovery process.
The following example is illustrative: One spouse expressed
great fear for her husbands situation. The husband, however,
remained quite passive. When the spouse was encouraged to tell
more about her fears, she explained that she always had taken
care of him and that she now considered it as her responsibility
that everything went well. In fact she was very afraid that he

231

should die. On this background, the couple was now informed

that the treatment had been successful and that his prospects
were good. Further, that a successful rehabilitation process
primarily depended on him, but that her support in this process
of course was important. She could now rely more on the
medical advice, and not demand so much of herself. She then
admitted that she wanted to use more time on her own activities
outside home and that she was relieved that she did not have to
stay so much at home in order to look after her husband. During
the session, the patient gradually became more active and
motivated to follow the advice for life style changes. The
dependency pattern within their relationship was not commented on by the nurses, but we may suppose that her dominant
role had a pacifying effect upon him. She was encouraged to
take more care of herself and he was confronted with the
importance that he became the main person in his own
rehabilitation process.
4. Discussion and conclusions
4.1. Discussion
Meeting the needs for information, care and support to the
highly stressed CABG patients can be challenging for the ward
nurses. Providing the same information to all patients according
to a checklist may indeed enable the nurses to provide a high
amount of detailed information in a short time, but this
approach may also fail to meet the patients needs for care and
support.
The overall aim of the patient-centred information
procedure was to improve patient satisfaction and outcome.
The effects of the patient-centered approach in combination
with video information were tested in a randomized trial
reported in a previous paper [44]. Compared with patients
getting the standardized information procedure, patients in the
intervention group reported significantly less anxiety and better
subjective health at discharge and during the whole follow-up
period of 2 years after discharge. They also reported
significantly lower depression scores 1 and 2 years following
discharge.
In this paper we have described the nurse training
procedures for the patient-centred information approach. The
nurses found the patient-centered principles in accordance with
what they had learned in their nurse training at University
College. However, they had gradually become socialized to the
traditional nurse-centered approach due to increased focus and
demand for efficiency improvements at the ward. Initially, the
nurses interacted with the patients according to the traditional
approach, but when given alternative and more patient-centered
ways of relating to the patients, they started to use this new
approach. The guidelines and list of recommended behaviors
were useful tools guiding the group discussions and stimulating
awareness and reflection of the dynamics of the nursepatient
interaction.
Patients behaviors may easily provoke emotional reactions
in nurses. Awareness of these feelings and how they may
interfere with the nursepatient interaction is a requisite to

232

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

provide professional care to the patients. The small group

format for training seemed particularly useful for enabling and
supporting awareness of these processes.
Patient-centeredness involves patients as active participants
in their own health care. It has been argued that adults are
inherently striving to be independent and self-directed and
therefore should be active participants in their educational
process [53]. Consequently, patients should be stimulated to
identify and formulate their own learning needs and learning
priorities. Addressing concerns of personal importance may
help the patient to exert control within a learning environment.
Conversely, a treatment environment structured solely by the
staff can reinforce the patients sense of dependence and
undermine the learning process.
The example of the worried spouse illustrates how social
relations both can stimulate and constrain patients active selfregulation. Meeting the needs of the spouse revealed how the
spouses fear and irrational beliefs affected the patients ability
and conditions to take active responsibility of his own health.
Inaccurate and irrational representations of illness and
treatment are frequent among coronary patients, and the
overestimation of risk is associated with higher levels of
anxiety [54]. This was illustrated in the case with the young
man who initially avoided any dialogue. His irrational fear
constrained a positive self-regulation.
The active process of acquiring information and relating it to
personal experiences, allows the patient to construct realistic
mental representations of the illness and the treatment. This
may help the patient to find meaning in the experience, to
reduce distress, to seek out new information, as well as to plan,
evaluate, and modify coping strategies. In these processes the
patient is the active agent, and the main task for the nurse is to
stimulate and support the patients self-regulation.
4.2. Conclusions
Nurses found the patient-centered approach useful in their
work with CABG patients. The training procedure combining
audio-recordings and group training sessions stimulated reflection on critical aspects of nursepatient interactions. The training
generated illustrative cases of how the patient-centered approach
could be applied in nursepatient interaction.
4.3. Practice implications
This training which requires minimal resources and can be
easily implemented, may guide the nurses in their interaction
with patients. Providing a patient-centered approach to the
CABG patients may enhance the nursepatient contact and
improve patients hospital experience and subjective health.
The nurses experienced the training as a professional challenge
and a motivation in their clinical work. We expect that
implementing the training as a routine procedure would
improve the professional competence and increase job
satisfaction among the nurses.
However, the progress in implementing the training
procedures in routine practice has been slow. Several factors

may contribute to this: The ward is characterized by a heavy

workload, a high turnover among nurses and limited economic
resources for developing professional routines. Further, the
current Norwegian financing system for hospitals does not
provide economical resources for psychosocial interventions.
Access to a psychiatrist to facilitate the development of a nurse
training procedure grounded in psychosocial theory, while
potentially infeasible at other hospitals, may have been
paramount to the success of this program in creating
improvements in CABG patients psychosocial status. Institutional support for such a program will be critical to its long-term
success and effectiveness. Despite these limitations, implementation may be possible if a training and implementation
program is elaborated and given priority by the Head of the
Department. The program should include explicit training and
evaluation procedures and be approved by the National
Association of Nurses and the health authorities as a formalized
postgraduate training program for the nurses.
We confirm that all patient/personal identifiers have been
removed or disguised so the patient/person(s) described are not
identifiable and cannot be identified through the details of the
story.
Acknowledgements
We thank the participating nurses and patients. The study
was supported by a grant from the Northern Norway Regional
Health Authority, the University of Troms, and from the
Norwegian Research Council (the FRIHUM-programme).
References
[1] Breemhaar B, van den Borne HW, Mullen PD. Inadequacies of surgical
patient education. Patient Educ Couns 1996;28:3144.
[2] Dunckley M, Ellard D, Quinn T, Barlow J. Recovery after coronary artery
bypass grafting: patients and health professionals views of the hospital
experience. Eur J Cardiovasc Nurs 2007;6:2007.
[3] Gardner G, Elliott D, Gill J, Griffin M, Crawford M. Patient experiences
following cardiothoracic surgery: an interview study. Eur J Cardiovasc
Nurs 2005;4:24250.
[4] Koivula M, Tarkka MT, Tarkka M, Laippala P, Paunonen-Ilmonen M. Fear
and in-hospital social support for coronary artery bypass grafting patients
on the day before surgery. Int J Nurs Stud 2002;39:41527.
[5] Koivula M, Tarkka MT, Tarkka M, Laippala P, Paunonen-Ilmonen M. Fear
and anxiety in patients at different time-points in the coronary artery
bypass process. Int J Nurs Stud 2002;39:81122.
[6] Mahler HI, Kulik JA. Preferences for health care involvement, perceived
control and surgical recovery: a prospective study. Soc Sci Med
1990;31:74351.
[7] Srlie T, Sexton H. The factor structure of The Ways of Coping
Questionnaire and the process of coping in surgical patients. Pers Indiv
Differ 2001;30:96175.
[8] Contrada RJ, Leventhal EA, Anderson JR. Psychological preparation for
surgery: marshalling individual and social resources to optimize selfregulation. Int Rev Health Psychol 1994;3:21966.
[9] Duits AA, Duivenvoorden HJ, Boeke S, Taams MA, Mochtar B, Krauss
XH, Passchier J, Erdman RAM. The course of anxiety and depression in
patients undergoing coronary artery bypass graft surgery. J Psychosom
Res 1998;45:12738.
[10] Lavie CJ, Milani RV. Prevalence of anxiety in coronary patients with
improvement following cardiac rehabilitation and exercise training. Am J
Cardiol 2004;93:3369.

S. Bergvik et al. / Patient Education and Counseling 70 (2008) 227233

[11] Rymaszewska J, Kiejna A, Hadrys T. Depression and anxiety in coronary
artery bypass grafting patients. Eur Psychiat 2003;18:15560.
[12] Shah SU, White A, White S, Littler WA. Heart and mind: (1) relationship
between cardiovascular and psychiatric conditions. Postgrad Med J
2004;80:6839.
[13] Vingerhoets G. Perioperative anxiety and depression in open-heart surgery. Psychosomatics 1998;39:307.
[14] Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME. Coronary
artery disease and depression. Eur Heart J 2004;25:39.
[15] Borowicz Jr L, Royall R, Grega M, Selnes O, Lyketsos C, McKhann G.
Depression and cardiac morbidity 5 years after coronary artery bypass
surgery. Psychosomatics 2002;43:46471.
[16] Lett HS, Blumenthal JA, Babyak MA, Sherwood A, Strauman T, Robins
C, Newman MF. Depression as a risk factor for coronary artery disease:
evidence, mechanisms, and treatment. Psychosom Med 2004;66:30515.
[17] Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical
outcomes: an evidence-based literature review. J Am Acad Orthop Surg
2006;14:397405.
[18] Liao L, Jollis JG, DeLong ER, Peterson ED, Morris KG, Mark DB. Impact
of an interactive video on decision making of patients with ischemic heart
disease. J Gen Intern Med 1996;11:3738.
[19] Mahler HI, Kulik JA. Effects of preparatory videotapes on self-efficacy
beliefs and recovery from coronary bypass surgery. Ann Behav Med
1998;20:3946.
[20] Mahler HI, Kulik JA, Tarazi RY. Effects of a videotape information
intervention at discharge on diet and exercise compliance after coronary
bypass surgery. J Cardiopulm Rehabil 1999;19:1707.
[21] Gottlieb BH. Marshalling social support: formats, processes and effects.
Newbury Park, CA: Sage; 1988.
[22] Horne DJ, Vatmandis P, Careri A. Preparing patients for invasive medical
and surgical procedures: using psychological interventions with adults and
children. Behav Med 1994;20:1521.
[23] Johnston M, Vogele C. Benefits of psychological preparation for surgery: a
meta-analysis. Ann Behav Med 1993;15:24556.
[24] Miro` J, Raich RM. Preoperative preparation for surgery: an analysis of the
effects of relaxation and information provision. Clin Psychol Psychother
1999;6:2029.
[25] OHalloran CM, Altmaier EM. The efficacy of preparation for surgery and
invasive medical procedures. Patient Educ Couns 1995;25:916.
[26] Martelli MF, Auerbach SM, Alexander J, Mercuri LG. Stress management
in the health care setting: matching interventions with patient coping
styles. J Consult Clin Psychol 1987;55:2017.
[27] Wegner NK. Rehabilitation of the coronary patient: a preview of tomorrow. J Cardiopulm Rehabil 1991;11:938.
[28] Thomas JJ. Reducing anxiety during phase 1 cardiac rehabilitation. J
Psychosom Res 1995;39:295304.
[29] Bensing J. Bridging the gap: the separate worlds of evidence-based
medicine and patient-centered medicine. Patient Educ Couns
2000;39:1725.
[30] Graugaard PK, Finset A. Trait anxiety and reactions to patient-centered
and doctor-centered styles of communication: an experimental study.
Psychosom Med 2000;62:339.
[31] Mead N, Bower P. Patient-centredness: a conceptual framework and
review of the empirical literature. Soc Sci Med 2000;51:1087110.
[32] Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K,
Payne S. Observational study of effect of patient centredness and positive
approach on outcomes of general practice consultations. Brit Med J
2001;323:90811.

233

[33] Mead N, Bower P. Patient-centred consultations and outcomes in primary

care: a review of the literature. Patient Educ Couns 2002;48:5161.
[34] Zandbelt LC, Smets EMA, Oort FJ, Godfried MH, de Haes H. Patient
participation in the medical specialist encounter: does physicians patientcentred communication matter? Patient Educ Couns 2007;65:396406.
[35] Michie S, Miles J, Weinman J. Patient-centredness in chronic illness: what
is it and does it matter? Patient Educ Couns 2003;51:197206.
[36] Wynn R. Provider-patient interactiona corpus-based study of doctorpatient and student-patient interaction. Kristiansand: Norwegian Academic Press; 1999.
[37] de Haes H, Koedoot N. Patient centered decision making in palliative
cancer treatment: a world of paradoxes. Patient Educ Couns 2003;50:
439.
[38] Lauver DR, Ward SE, Heidrich SM, Keller ML, Bowers BJ, Brennan PF,
Kirchhoff KT, Wells TJ. Patient-centered interventions. Res Nurs Health
2002;25:24655.
[39] van Weert J, van Dulmen S, Bar P, Venus E. Interdisciplinary preoperative
patient education in cardiac surgery. Patient Educ Couns 2003;49:10514.
[40] Cameron LD, Leventhal H. The self-regulation of health and illness
behaviour. London: Routledge; 2003.
[41] Carver CS, Scheier MF. On the self-regulation of behavior. Cambridge:
Cambridge University Press; 2001.
[42] Leventhal H, Brissette I, Leventhal EA. The common-sense model of selfregulation of health and illness. In: Cameron LD, Leventhal H, editors.
The self-regulation of health and illness behaviour. London: Routledge;
2003. p. 4265.
[43] Backstrom S, Wynn R, Srlie T. Coronary bypass surgery patients
experiences with treatment and perioperative carea qualitative interview-based study. J Nurs Manage 2006;14:1407.
[44] Srlie T, Busund R, Sexton J, Sexton H, Srlie D. Video information
combined with individualized information sessions: effects upon emotional well-being following coronary artery bypass surgerya randomized trial. Patient Educ Couns 2007;65:1808.
[45] Srlie T, Sexton H, Busund R, Srlie D. Predictors of satisfaction with
surgical treatment. Int J Qual Health Care 2000;12:3140.
[46] Giorgi A. The theory, practice, and evaluation of the phenomenological
method as a qualitative research procedure. J Phenomenol Psychol
1997;28:23560.
[47] Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:142333.
[48] Horvath A. Research on the alliance. In: Horvath A, Greenberg LS,
editors. The working alliance: theory, research and practice. New York:
Wiley; 1994. p. 25986.
[49] Rogers C. Counseling and psychotherapy. Boston: Houghton-Mifflin;
1942.
[50] Leventhal H, Diefenbach M. The active side of illness and cognition. In:
Skelton JR, Croyle RT, editors. Mental representations in health and
illness. New York: Springer; 1991. p. 24772.
[51] Schroder KE, Schwarzer Ralf. Habitual self-control and the management
of health behavior among heart patients. Soc Sci Med 2005;60:85975.
[52] Stakes RE. Case studies. In: Denzin NK, Lincoln YS, editors. Handbook
of qualitative research. Thousand Oaks, CA: Sage; 1994. p. 23647.
[53] Knowles MS. The adult learner: a neglected species, 4th ed. Houston,
Gulf; 1990.
[54] Broadbent E, Petrie KJ, Ellis CJ, Anderson J, Gamble G, Anderson D,
Benjamin W. Patients with acute myocardial infarction have an inaccurate
understanding of their risk of a future cardiac event. Intern Med J
2006;36:6437.